Gerald T. Keusch, M.D. Associate Provost and Associate Dean for Global Health, Boston University

1. Building Health Partnerships Between Developed-Developing Country UniversitiesIs Academia Relevant to Global Health? Gerald T. Keusch, M.D. Associate Provost and Associate Dean for Global Health, Boston University

2. Organization of presentation • Health disparities - scene setting • Where have we come from? • Where are we now? • Where are we going • Partnerships • Intended and unintended consequences

3. Health disparities are quantitative

4. Health disparities are also qualitative • Populations with Equal Access to Health Care SOURCE: Gomes and McGuire Unequal Treatment, Confronting Ethnic and Racial Disparities in Health Care National Academy of Sciences, 2001

5. Global health disparities are even greater…

6. 80 70 60 50 40 30 1990 1960 About 1930 Life Expectancy (Years) About 1900 0 5,000 10,000 15,000 20,000 25,000 Income Per Capita, 1991 International Dollars related to poverty…

7. related to particular diseases…

8. and not getting better for those at the very bottom of the barrel. WHO Macroeconomics Report, 2001

9. Given these realities, what would you want in your fortune cookie? Its why its called a fortune cookie!

10. Where have we come from?

11. A century of medical science. Successes in the 20th Century - • Imaging, X-ray to MRI • Immunology, a new science • New vaccines, from polio to HPV • Eradication of an ancient pathogen • Behavioral risk factors – tobacco, diet • Pathology to molecular/cellular biology • Receptors, signaling, molecular cross-talk • Genetic sciences and the human genome • Omics, systems biology, bionics, designer meds

12. A century of medical science:Disappointments of the 20th century • Increasing disparities in health • Failure to use available technology • Increasing disparities in health research • Knowledge doesn’t equal problem solving • More people affected by neglected diseases • Rise of a for profit pharmaceutical industry that must focus R&D on the business bottom line • Impact on access, availability, affordability, appropriateness, acceptability • Excessive attention to life-style drugs • Inattention to neglected tropical diseases

13. The Dilemma of Public Health • Public health is the art and science of making sure nothing happens • When nothing happens, nobody notices • Politicians worry when nothing happens – “nothing” is a political vacuum • When asked to pay for nothing they balk • When they pay and nothing happens they get mad • When they balk or they get mad the public health system suffers…until something happens • When something happens, everybody is blamed, especially the public health system and its “failed” leadership who “mislead” the politicians

14. No wonder expenditures on public health are so low (data from the U.S.) <5%

15. Where are we now?

16. The present global context: • Poverty: billions live on less than $2/day; health expenditures are woefully inadequate. • Population: > 6 billion and growing. • Environment: Continuing degradation, climate change, pollution and disease spread. • Civil Society: Civil and foreign wars, genocide, displaced persons, refugees and migration, failed states. • Health: 95% of global disease burden is in the developing countries and local expenditures are grossly inadequate. • Research: > 90% of $$ is for first world diseases so little is spent on disease affecting the majority – too much oriented to highly technical, expensive drugs, diagnostics or devices.

17. But, growing recognition of the importance of global issues Globalism as the 21st century theme The response to a changing world The social conscience of students Health as a key global concern Health is the basis for development Health as a human right Health as a security issue Centrality of health to international policy Core aspiration of all nations Role of health in “soft” diplomacy

18. The Essential Premise: There are many sectors but just one, health, is central to all others ECONOMICS POLITICS BUSINESS HEALTH CIVIL SOCIETY ARTS AND CULTURE AGRICULTURE

19. A Definition of Global Health: New Field or New Name? Koplan, J.P. et al, for the Consortium of Universities for Global Health Global health is a field of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants and/or solutions; involves multiple disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual level clinical care.

20. Where are we going?

21. Unless things change dramatically what will happen in the 21st century? • More old, more young • More poor, more hungry • More crowding, more pollution • More degradation of environment • More discrepancy in access to resources • More resentment, political instability, violence • More social disruption, failed states, terrorism

22. How can health be improved and disparities reduced in developing countries? • Figure out what the problems are • Applied as well as basic and translational research • Can involve students as well as faculty • Get into the field, in facilities and the community • Identify potential solutions • Facility or community based • Be sure they are culturally appropriate • Implement interventions • Funding/staffing • Capacity building

23. A transforming publication for university global health programs

24. Increased scientific knowledge has accounted for much of the dramatic improvement in health that has occurred in this century—by providing information that forms the basis of household and government action and by underpinning the development of preventive, curative, and diagnostic technologies… Because the fruits of science benefit all countries, internationally collaborative efforts, of which there are several excellent examples, will often be the right way to proceed. The most important unanticipated finding in the 1993 World Development Report (according to Dean Jamison, lead author)

25. What do universities do? What is their role in society? Universities have four critical roles • Education – (including education of the public at large), but this may be relegated to 2nd place in some research intensive institutions • Research – generation of new knowledge • Service – translation and application of knowledge in society • Policy – inform the political sector, influence decision making

26. Education: responsibility of the university as the Academy • Teach global literacy – business students need to understand the magnitude of disparities in health, science students need to understand the practical value of their work, all students need to know about the real world • Make global studies a required part of the core curriculum • Contribute to improvement of K-12 education in science and technology • Promote public access to the health literature • Encourage publication in open access journals • Find venues to publish work that doesn’t work • Speak in plain language to the public

27. Research: knowledge creation – upstream, downstream or all stream? • Embrace a global culture of science with high ethical standards, open and free communication, concern for global public goods • Reduce barriers between academic faculties and promote interdisciplinary research • Connect basic and applied research within the research culture • Reward applied research productivity by faculty through recognition, support, academic promotions • Establish thoughtful socially relevant intellectual property policies and licensing terms: knowledge as a global public good

28. Appropriate university engagement in service and policy development • Contribute to capacity building in science, clinical medicine, and public health • Support training of developing country health workers in a manner that does not lead to emigration • Work more directly with international agencies to improve health and health capacity in developing countries • Promote the good side of globalization, correct the bad • Enter national policy decision making process to insure that evidence is used effectively • University Consortium for Global Health • National Academy of Science/Institute of Medicine • Advocacy

29. Building Health Partnerships Between Developed and Developing Country Universities

30. Sustainable, EffectiveBuilding ^ Health Partnerships Between Developed and Developing Country Universities

31. What are the essential features of sustainable effective partnerships? Innovative PH model Traditional Business model

32. The new governance paradigmRobert Klitgaard, President Claremont Univ. From “layer cake” (tasks taken on separately by different sectors) to “marble cake” (cross sectoral partnerships). In research we call it interdisciplinarity There are three key questions: • What’s in it for me (my institution)? • What will my partner contribute? • What will it cost me?

34. Three essential features: • Trust • Trust • Trust

35. Three essential attitudes: • Respect • Respect • Respect

36. These create the three essential enabling features for successful partnerships: • Relationships • Relationships • Relationships Who your “ambassadors” are does really matter.

37. What can academics do? • Improve access to information, globally – publish in open access journals • Develop sustained collaborations with developing country scientists for training, research, and improving clinical services • Advocate for “better” (more enlightened) tech transfer policies – understand IP and TT • Organize and become vocal advocates for appropriate assistance to developing countries for capacity building and service • Canadian version of the newly announced Obama initiative in Global Health • Work with IRDC – an inherently good agency Science for Humanity

38. What can institutions do? Value applied research in career development, e.g. work on rapid low-tech low-cost diagnostics

39. Create new mechanisms for risky research: Professorships of Failed Experiments

40. Intended consequences • Progression to integrative partnership model • Capacity improvements • Managerial competence • Good governance – transparent, fair, ethical • Meaningful health benefits • Learning lessons become bidirectional

41. Unintended consequences • Neocolonialism – control issues • Introduction of inappropriate technology • Displaced concern – e.g. from local problems to hosting international students • Cultural clashes • Facility based focus • Research dominance – leadership roles, authorship/presentation of data

42. Can we deliver what we promise? Partner McGill “I think I can make you very happy if I can get funded.”

43. Today…

44. Backslide tomorrow?Personal/institutional persistence and focus